Failure of Leaders to Respond to Reports of Sexual Harassment at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota

The VA Office of Inspector General (OIG) reviewed the administrative and clinical responses by facility leaders and staff to allegations of a patient’s report of sexual harassment at the VA Black Hills Health Care System (facility) in Fort Meade and Hot Springs, South Dakota. A patient participating in the Compensated Work Therapy program and the Transitional Residence program reported being sexually harassed by a food service coworker and subsequently died by suicide. The patient initially reported being sexually harassed to a Transitional Residence staff member while a permanent employee residing in a Transitional Residence house. Later that same year, the patient reported to the VA police that the sexual harassment began while participating in the Compensated Work Therapy program. Participants in Compensated Work Therapy and Transitional Residence programs are considered patients and not employees. The OIG determined facility leaders did not take administrative actions that aligned with policy when the patient reported being sexually harassed. Facility leaders understood that the interactions occurred after hours, off VA property, and between two employees, and therefore, no action could be taken. Although the Compensated Work Therapy and Transitional Residence program manager knew that the patient was a participant in the Transitional Residence program, and therefore considered a patient, the program manager took no action, such as speaking with the patient, upon learning of the patient’s report of sexual harassment. The OIG determined that the Transitional Resident staff member and counselor provided clinical support. The OIG made three recommendations related to the reviews of the sexual harassment policy and the actions of the Transitional Residence program manager, and to ensure that the facility policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.